Provider Demographics
NPI:1568903573
Name:ROSCOMMON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ROSCOMMON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-821-9222
Mailing Address - Street 1:188 PINE BLUFFS RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-8328
Mailing Address - Country:US
Mailing Address - Phone:989-281-9222
Mailing Address - Fax:989-821-4981
Practice Address - Street 1:188 PINE BLUFFS RD
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-8328
Practice Address - Country:US
Practice Address - Phone:989-281-9222
Practice Address - Fax:989-821-4981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI141321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty